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Patterns of care amongst older adults diagnosed with locally advanced esophageal cancer: A cohort study

  • Charles E. Gaber
    Correspondence
    Corresponding author.
    Affiliations
    University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA
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  • Nicholas J. Shaheen
    Affiliations
    University of North Carolina at Chapel Hill, School of Medicine, Department of Medicine, 21 S Columbia St, Chapel Hill, NC 27516, USA
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  • Robert S. Sandler
    Affiliations
    University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA

    University of North Carolina at Chapel Hill, School of Medicine, Department of Medicine, 21 S Columbia St, Chapel Hill, NC 27516, USA
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  • Jessie K. Edwards
    Affiliations
    University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA
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  • Hazel B. Nichols
    Affiliations
    University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA
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  • Hanna K. Sanoff
    Affiliations
    University of North Carolina at Chapel Hill, School of Medicine, Department of Medicine, 21 S Columbia St, Chapel Hill, NC 27516, USA
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  • Jennifer L. Lund
    Affiliations
    University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Drive, CB #7435, Chapel Hill, NC 27599-7435, USA
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Published:August 22, 2022DOI:https://doi.org/10.1016/j.jgo.2022.08.009

      Abstract

      Introduction

      Since the early 2010s, neoadjuvant chemoradiation followed by esophagectomy (trimodal therapy) has been a recommended treatment for patients diagnosed with locally advanced esophageal cancer. However, it may also add treatment-related toxicity, particularly for older adults with significant comorbidity and frailty burdens. We examined contemporary patterns of care in older adults, which have not been well characterized.

      Materials and Methods

      We used the Surveillance Epidemiology and End Results-Medicare database to identify a cohort of US adults aged 66 years and older diagnosed with incident locally advanced esophageal cancer between 2004 and 2017. Calendar year age-standardized percentages of treatment receipt were calculated. Joinpoint regression was used to detect temporal trends in treatment receipt. Descriptive associations between patient factors and treatment were assessed. Trend analyses quantified how the percentage of trimodal and definitive chemoradiation (no surgery) patients receiving cisplatin-based, carboplatin-based, and other chemotherapy regimens evolved over time.

      Results

      In total, 4332 adults aged ≥66 years with locally advanced esophageal cancer were included. The age-standardized percentage of patients receiving trimodal therapy increased from 16.7% in 2004 to 26.1% in 2017 (annual percent change = 3.5%; 95% confidence interval [CI], 0.7%–6.4%) in adenocarcinomas and from 7.3% in 2004 to 9.1% in 2017 (annual percent change = 0.4%; 95% CI, −4.1%–5.1%) in squamous cell carcinomas. By 2017, definitive chemoradiation became the most frequently used treatment modality for adenocarcinomas (49.8%; 95% CI, 43.5–56.0) and squamous cell carcinomas (59.5%; 95% CI, 50.8–68.2). Patients with higher comorbidity and frailty burdens were less likely to be treated with trimodal therapy. Amongst patients receiving chemoradiation as part of their treatment, a large and swift channeling away from cisplatin and towards carboplatin-based regimens was observed.

      Discussion

      In practice, definitive chemoradiation is the most commonly received treatment by older adults with locally advanced esophageal cancer. Four out of five older adults do not receive trimodal therapy, some of whom are potentially undertreated.

      Keywords

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